Ischemic stroke

Monitoring parameters for patients on intravenous alteplase as per American Heart Association/American Stroke Association (AHA/ASA) guidelines:[119]Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-418. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000211 http://www.ncbi.nlm.nih.gov/pubmed/31662037?tool=bestpractice.com

• Admit the patient to a stroke unit for monitoring

• Perform blood pressure and neurologic assessments every 15 minutes during and after intravenous alteplase infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours after intravenous alteplase treatment

• If the patient develops severe headache, acute hypertension, nausea, or vomiting, or has a worsening neurologic examination, discontinue the infusion and obtain emergency CT scan

• Increase the frequency of blood pressure (BP) measurements if a systolic BP is ≥180 mmHg or if a diastolic BP is ≥105 mmHg; administer antihypertensive medications to maintain BP at or below these levels

• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them

• Obtain a follow-up CT or MRI scan at 24 hours after intravenous alteplase before starting anticoagulants or antiplatelet agents.

Further monitoring may be required for secondary prevention of ischemic stroke. For example, cardiac monitoring for atrial fibrillation should be carried out at initial assessment and continued throughout treatment of acute stroke. The AHA/ASA guidelines recommend continuous cardiac monitoring for at least the first 24 hours after stroke.[119]Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-418. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000211 http://www.ncbi.nlm.nih.gov/pubmed/31662037?tool=bestpractice.com Further outpatient monitoring may be carried out for patients with cryptogenic stroke and suspected paroxysmal arrhythmias, particularly if they had a short admission and brief monitoring.